Some upheld, recommendations

Summary

Mr C complained that the college had not responded reasonably to his allegation of bullying. We found that the college had initially acted promptly, but had then failed to investigate the matter in line with the relevant policy. Mr C also complained that they had not acted reasonably in respect of a work placement. We found that the college had been entitled to raise concerns with Mr C about his behaviour. We considered that they had acted reasonably in relation to this matter and did not uphold this aspect of the complaint.

Mr C also complained that staff had failed to treat him with courtesy and respect during a meeting and that they did not give him a reasonable opportunity to answer questions during another meeting. We found that there had been differing versions of these meetings. We did not uphold these complaints, as there was no objective evidence to either support or refute Mr C's allegations. Finally, Mr C complained that the college had failed to reasonably investigate and respond to his complaints. We found that the college had not responded to him within the timescale they had referred to and they had not kept him updated. The college also failed to fully explore some of the comments in Mr C's complaint. In view of these failings, we upheld this aspect of the complaint.

Recommendations

We recommended that the college:

• issue a written apology to Mr C for the failings identified;
• remind staff of the requirement to investigate allegations of bullying in line with the relevant policy; and
• make complaints handling staff aware of our decision.

Summary

Mr C complained that his prison unreasonably put him on closed visits, and that there was an unreasonable delay in the prison responding to his complaints about confidential matters (known as PCF2 complaints). In dealing with Mr C's complaint, we explained to him that the decision to put him on closed visits was a discretionary matter for the prison under The Prisons and Young Offenders Institutions (Scotland) Rules 2011 (the prison rules). Our role was to see whether the prison followed the correct procedure.

We looked at the Scottish Prison Service (SPS)'s file on Mr C's complaint, their records about the closed visits and relevant SPS procedures. We found that the prison rules gave the prison governor the authority to put a prisoner on closed visits, and that the prison had reviewed Mr C's status for closed visits regularly, which was in line with the prison rules and the prison's own process. Therefore, we did not uphold this part of Mr C's complaint.

We also found that there was a delay in the prison responding to two of Mr C's PCF2 complaints, which was not in line with the SPS complaints procedure. In addition, there was an excessive delay in the prison responding to a letter from Mr C's solicitor, which was related to his complaints. Therefore, we upheld this part of Mr C's complaint.

Recommendations

We recommended that SPS:

• remind relevant prison staff of the SPS complaints guidance relating to PCF2 complaints.

Summary

Mr C complained to us about the council's handling of a planning application for additional parking along his parents' street. He said that the council had not fully considered several material planning considerations when they granted consent with conditions, and that he had not been given an opportunity to speak at the council meeting when the application was determined. He also complained that, when he reported to the council that conditions on the planning consent had not been met, the council did not take any enforcement action.

We took independent advice from a planning adviser. He noted the procedures which the council had implemented in handling the planning application, and the presentation of the various different issues raised as objections to the application. He reviewed how these had been presented and considered in the report on the application, and considered that the council had taken a reasonable approach to each of the concerns raised. The adviser also noted appropriate consultations with the council's roads department. He reviewed the procedures in relation to public hearings, and was satisfied that the council had applied these appropriately. In terms of following up on the conditions of the consent, the adviser was satisfied that the approach taken by the council had been reasonable, though they noted the extended timescales involved, which were not in line with the council's Enforcement Charter.

We found that the council had followed their procedures appropriately in relation to their consideration and determination of the planning application. We also considered that it was in line with their policies not to allow for public presentations at the council meeting, in relation to this application. In relation to potential enforcement action, we were satisfied that they had taken a reasonable approach in not taking formal enforcement action. However, we were critical that they had not taken prompt action, and that they had not kept Mr C informed of what was happening.

Recommendations

We recommended that the council:

• apologise to Mr C for the slow responses to his enquiries and provide him with information about what work remains outstanding, when the council expect completion, and what action they will take if conditions remain outstanding.

Summary

Mr C complained to the council that, contrary to the terms of a planning consent, they had allowed an existing road to be 'grubbed out' before a new road was laid. He said that they failed to take enforcement action on this breach of consent and that they failed to take reasonable steps when he reported safety concerns about the new road access.

We took independent advice from a chartered town planner and we found that when Mr C complained about the old road being removed, the council acted on his concerns and made two site visits. The council determined that the new road was acceptable in safety terms and, on this basis, declined to take enforcement action. This was a discretionary decision that they were entitled to take, so we did not uphold this part of Mr C's complaint. However, although the council looked into Mr C's concerns about the new road access, they failed to give him a reasonable explanation as to why they did not intend to act on them. Because of this, we upheld this part of Mr C's complaint.

Recommendations

We recommended that the council:

• provide an appropriate apology; and
• ensure that the terms of our decision are brought to the attention of those members of staff in the roads and planning department who were involved in the planning applications concerned.

Summary

Mr C complained about the care and treatment of his late wife (Mrs C) during several admissions to Western Isles Hospital, following a fall. Mr C said they were initially told there were no breaks or fractures, but he found out over a week later that in fact Mrs C had several rib fractures. He then found out several weeks after this that Mrs C also had a fractured vertebra. Mr C complained about the delay in diagnosing the fractures, and raised concerns about the overall medical and nursing care. He also said staff told him he would be refunded for his expenses when he accompanied Mrs C to a hospital on the mainland, but the board later refused to reimburse him.

The board explained that Mrs C was very ill, with a severe chest infection and a number of medical conditions. They said the rib fractures appeared to be old, and would not have changed her treatment. They also said Mr C was not eligible to be reimbursed for his expenses under their travel policy (and they had updated their information leaflet to make this clearer). The board agreed that some aspects of Mrs C's care could have been better, in particular management of her diabetes, and they took actions to improve this.

After taking independent medical and nursing advice, we upheld two of Mr C's complaints. We were not critical that staff did not identify Mrs C's fractures on the original x-rays, but we were concerned that there was a delay in the reporting of scans, which meant that staff were unaware of Mrs C's fractures for some time. We also found that staff failed to investigate a new symptom of pain when Mrs C returned to hospital a few days after her fall. Finally, we found there was evidence that nursing staff thought Mr C was eligible for reimbursement under the travel policy (so it was likely they gave him inaccurate information about this).

Recommendations

We recommended that the board:

• feedback our findings to the staff involved for reflection and learning;
• review their process for reporting on x-rays to ensure reports are completed within a reasonable timeframe;
• ensure relevant staff discuss the radiology adviser's comments on the scan at a discrepancy meeting;
• apologise to Mr C for the failings our investigation identified; and
• remind staff that the travel policy does not apply in relation to patients transferred by ambulance, or patients transferred between treatment centres.

Summary

Mr C complained about the care and treatment of his mother (Mrs A), who was admitted to Perth Royal Infirmary following some falls, and then transferred to Murray Royal Hospital for assessment. Mrs A remained in Murray Royal Hospital for about three months, although she was transferred back to Perth Royal Infirmary on several occasions.

During Mrs A's time at Murray Royal Hospital, Mr C made allegations of abuse by nursing staff, and he complained that the board did not investigate this properly. Mr C also raised concerns about Mrs A's nursing and medical care at Murray Royal Hospital. These included concerns about her falls and physical safety, the numerous transfers between hospitals, the delay in replacing Mrs A's dentures, Mrs A's medications, and the decisions to detain Mrs A under the Mental Health Act and to use covert medication. Mr C also said the board failed to reimburse him for items lost during Mrs A's admission.

The board apologised to Mr C for the time taken to replace Mrs A's dentures and for the lost items. They arranged several reviews of Mrs A's care in response to Mr C's complaint, but found her care was satisfactory.

After taking independent advice from a mental health adviser and an adviser who is a consultant in general medicine, we upheld two of Mr C's complaints. We found there had been some failings in nursing care, including inadequate care planning (particularly in relation to falls risk) and inadequate nutrition monitoring. We also found the board failed to agree a clear communication plan with Mr C. However, we found that Mrs A's medical care was reasonable, and the decisions to detain Mrs A and use covert medication were made appropriately and in line with relevant guidance. We also found that, although the board had not yet reimbursed Mr C for all the missing items, they had handled his claim reasonably.

Recommendations

We recommended that the board:

• apologise to Mr C for the overall failings our investigation found;
• feed back the findings of our investigation regarding falls prevention, care planning and nutrition monitoring to the staff involved for reflection and learning;
• take steps to ensure individualised care planning is used to proactively identify and address patients' comprehensive care needs;
• review the use of communication plans for relatives and carers at Murray Royal Hospital; and
• review staff training needs in relation to falls prevention planning and responding to a fall (particularly where there is a suspected fracture).

Summary

Mrs C complained about the care her daughter (Miss A) received at Wishaw General Hospital's A&E department after she injured her knee. Mrs C said that it took several visits to the hospital before a magnetic resonance imaging scan (MRI - a scan which can show injuries to cartilage, ligaments and tendons) was carried out which identified a significant injury to Miss A's knee-cap. Mrs C was also dissatisfied with the orthopaedic department's communication with her in relation to Miss A's surgery.

We took independent advice from a consultant in emergency medicine and a consultant radiologist. We found that the x-ray performed at Miss A's initial presentation to the A&E department was interpreted satisfactorily. In addition, we took into consideration that knee injuries in general can be difficult to initially assess due to pain and swelling, so it was therefore appropriate that staff arranged a follow-up appointment. We did not find that there was any undue delay in carrying out the MRI scan which was arranged when Miss A's injury did not settle.

We concluded that the orthopaedic department should have explained more clearly to Mrs C what the operation entailed. This was acknowledged by the board but not reflected in their response to the complaint which we were critical of. Furthermore, they should have kept Mrs C pro-actively informed about the factors that affected the operation not going ahead on a particular day.

Recommendations

We recommended that the board:

• apologise for failing to respond to Mrs C's concerns about communication issues surrounding the operation and share these findings with relevant staff.

Summary

Ms C complained that the board failed to provide her with reasonable treatment for her thyroid problem. Ms C listed several issues regarding her care. She said that the consultant ear, nose and throat surgeon at the Southern General Hospital who dealt with her case underestimated the seriousness of the original scan and histology findings (report on the microscopic appearance of tissue). She complained that the surgeon unreasonably subjected her to repeat investigations and new referrals. She also complained that the surgeon ignored the final histology report which Ms C said confirmed she had cancer. Additionally, Ms C complained that the board did not respond reasonably to her complaint about her treatment.

We obtained independent advice on the complaint from a consultant surgeon specialising in ear, nose and throat, head and neck, and the thyroid gland. The adviser said that, given the length of time Ms C had had the nodule on her thyroid, the previous investigation of the nodule, and the fact there was no record of it having changed since it was first noted, the likelihood of malignancy (cancer) would have been low. The adviser explained that it was entirely reasonable for the consultant to undertake investigations before removing the nodule to check that there were no other medical issues which could cause problems with the anaesthetic and surgery.

The adviser did not consider that the consultant ignored the final histology report, just that they had not seen it. Ms C had moved house and was receiving treatment from another board by the time the consultant saw the report. However, the adviser said there was an unnecessary delay in the consultant noting and acting on the final histology report. This appeared to be caused by the process in the department for checking the results, and the board have indicated that action has been taken to improve this.

On balance, we considered that the board did not fail to provide Ms C with reasonable treatment. However, we also considered that the board did not respond reasonably to Ms C's complaint as there were inaccuracies in their response.

Recommendations

We recommended that the board:

• feed back our decision on Ms C's complaint about the treatment provided by the board to the staff involved; and
• provide Ms C with a written apology for the failings identified in both complaints.

Summary

Mr and Mrs C attended the Aberdeen Fertility Centre and were diagnosed with unexplained infertility. They underwent two in vitro fertilisation (IVF) cycles but neither cycle resulted in pregnancy. The board decided not to offer a further IVF cycle, saying that egg donation could be considered. Mr and Mrs C underwent assisted conception treatment privately. This found that Mrs C's ovarian reserve (the capacity of a woman's ovaries to produce healthy eggs) was higher than expected, and that Mr C's sperm had a significant number of antibodies which caused the sperm to stick together. Mrs C raised concerns about aspects of the assisted conception care and treatment provided by the Aberdeen Fertility Centre as well as the nursing care provided. She also raised concerns about the way the board handled their complaint.

We found that the board's actions were reasonable in relation to the provision of assisted conception. However, in light of the new information about the nature of the couple's infertility and Mrs C's ovarian reserve, we recommended that the board consider whether the couple met the board's eligibility criteria (as outlined in their policy) for a third round of IVF treatment. We also found communication and record-keeping failures by nursing staff, particularly around pain assessment and relief. In relation to the board's complaints handling, we found that the board should have told Mrs C about the delays in responding to her complaint, the reasons for the delays, and of her right to approach us in such circumstances.

Recommendations

We recommended that the board:

• consider whether Mr and Mrs C meet the eligibility criteria in the board's policy for a third cycle of assisted conception treatment in light of the new information about the nature of their infertility and Mrs C's ovarian reserve;
• bring the record-keeping and communication failures to the attention of relevant staff and review the process to ensure there is no recurrence;
• apologise for the failures identified in complaints handling and bring them to the attention of relevant staff; and
• apologise for the failures identified.

Summary

Mr A, who had a history of type 1 diabetes, chronic kidney disease and who had had a leg amputated, was admitted to Dumfries and Galloway Royal Infirmary in November 2013. He was complaining of chest pain, a shortage of breath and had an ulcerated toe. After admission, Mr A continued to be unwell and a week later, he had a cardiac arrest and died. His sister (Mrs C) complained that board staff failed to do enough for him or to recognise that he was a very sick patient. She also complained about the way in which her formal complaint was subsequently handled.

We took independent advice from a consultant geriatrician with an accreditation in general medicine and from a senior nurse. We found that Mr A's condition was a complex one and that doctors had treated him reasonably in terms of his symptoms and there were no reasonable precautions that could have been taken which could have prevented his death with certainty. We also found that the nursing care given to Mr A had been reasonable, although we identified some failure and shortcomings in record-keeping. We did not uphold Mrs C's complaints about care and treatment. However, we found that Mrs C's complaint had been dealt with badly. It did not initially progress through the complaints process and was beset by delay and confusion. Even when the board identified that this had happened, Mrs C was sent an inadequate reply. For these reasons, we upheld this part of the complaint.

Recommendations

We recommended that the board:

• remind the nursing staff involved in Mr A's care of their responsibility to keep appropriately detailed records;
• make a full apology for the delay and confusion in dealing with Mrs C's complaint; and
• ensure that they provide complaint responses that are thorough and appropriate.